| NPI | 1235666371 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC TL2782) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-10565) |
| Enumeration Date | 2017-05-19 |
| Last Update Date | 2024-08-12 |